Economic evaluation of high tibial osteotomy: Closing wedge is more cost-effective than open wedge technique when analysing the KOOS-12 improvement.

PURPOSE: The purpose of this study was to compare the cost-effectiveness of two techniques for performing a knee valgus osteotomy: opening wedge high tibial osteotomy (OW-HTO) vs closing wedge high tibial osteotomy (CW-HTO). METHODS: In this economic evaluation study, a cost-effectiveness analysis from the perspective of the Spanish public healthcare system was performed, comparing OW-HTO with CW-HTO. All patients with medial knee osteoarthritis who underwent one of these procedures between 2018 and 2020 in our institution were included. The cost analysis included operating room, implant, graft and hospital admission costs. Functional outcomes (KOOS-12, Tegner activity scale, pain and satisfaction) and radiological outcomes (hip-knee-ankle angle, medial proximal tibial angle, tibial slope and patellar height) were analysed. The cost-effectiveness ratio was obtained by calculating the cost of improving the minimal clinically important difference (MCID) of KOOS-12 for each procedure. All costs are expressed in 2020 euros. RESULTS: Fifty-one patients met the inclusion criteria (27 OW-HTO and 24 CW-HTO). Good to excellent functional outcomes, significant pain reduction (>6 points) and high patient satisfaction (>9/10) were observed in both groups. Both techniques yielded excellent radiological outcomes. N.s. differences in functional or radiological outcomes improvements between both procedures were found. However, the OW-HTO group presented a higher total cost than the CW-HTO group (4612.1 ± 765.6€ vs. 1827.1 ± 701.9€; p < 0.001). The cost-effectiveness ratio was 818.1 ± 46.8 €/MCID for the CW-HTO procedure and 2414.3 ± 115.2 €/MCID for the OW-HTO procedure (p = 0.025). CONCLUSION: The CW-HTO procedure presented a cost-effectiveness ratio almost three times lower than the OW-HTO procedure. Both techniques allowed to achieve of good to excellent functional outcomes, significant pain reduction and high patient satisfaction while correcting the varus limb malalignment and the metaphyseal tibial varus in patients with medial compartment osteoarthritis. LEVEL OF EVIDENCE: Level III; economic study.

Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes.

PURPOSE: Meniscal wrapping is a fully arthroscopic technique that involves enhanced meniscal repair with a tissue-engineered collagen matrix wrapping. This study aims to investigate the feasibility of using the meniscal wrapping technique for the treatment of chronic or complex meniscal tears. The primary objective is to assess its failure rate. The secondary objectives are to analyse complication rate, functional outcomes and overall patient satisfaction. METHODS: This retrospective case series study included patients who sustained chronic and complex tears undergoing meniscal wrapping with autologous liquid bone marrow injection. Failure rate was considered if the patient underwent partial or complete meniscectomy or knee replacement during the follow-up, while other unexpected knee reoperations were considered as complications. Clinical outcomes were evaluated through the IKDC score, Tegner Activity Score and Short Assessment of Patient Satisfaction. RESULTS: Twenty-one patients were included (15 non-acute bucket-handle tears, three non-acute horizontal tears and three non-acute complex injuries). The failure rate was 9.5% at 33 months. The rate of other unplanned reoperations was 14.3%, but none of these complications were apparently directly related to the wrapping technique. The average postoperative IKDC was 73.3/100. No statistically significant difference was encountered between preinjury and postoperative Tegner Activity Score. The mean overall patient satisfaction was 88.3/100. CONCLUSIONS: Meniscal wrapping can be safely used as an adjunctive technique to meniscal repair in such difficult-to-treat cases to preserve the meniscus. The technique achieves a low failure rate and promising results of knee function, and patient satisfaction.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

PURPOSE: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center.

PURPOSE: To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). MATERIALS AND METHODS: Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. RESULTS: MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6 years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. CONCLUSIONS: We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

Single-injection nerve blocks for total knee arthroplasty: femoral nerve block versus femoral triangle block versus adductor canal block-a randomized controlled double-blinded trial.

INTRODUCTION: Femoral nerve block (FNB) is a well-established analgesic technique for TKA. However, it associates quadriceps weakness. Therefore, femoral triangle block (FTB) and adductor canal block (ACB) were proposed as effective alternative motor-spearing techniques. The primary objective was to compare quadriceps muscle strength preservation between FNB, FTB and ACB in TKA. The secondary objective was to analyze pain control and functional outcomes. METHODS: This is a prospective, double-blinded RCT. From April 2018 to April 2019, patients who undergo a primary TKA were randomized into three experimental groups: FNB-G1/FTB-G2/ACB-G3. Quadriceps strength preservation was measured as the difference in maximum voluntary isometric contraction (MVIC) preoperatively and postoperatively. RESULTS: Seventy-eight patients (G1, n = 22; G2, n = 26; G3, n = 30) met our inclusion/exclusion criteria. Patients with FNB retained significantly lower baseline MVIC at 6 h postoperatively (p = 0.001), but there were no differences at 24 and 48 h. There were no differences between the groups in functional outcomes at any time point. Patients in the FNB-G1 presented significant lower pain scores at 6 h (p = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01). The highest cumulative opioid requirement was reported in ACB-G3. CONCLUSION: For patients undergoing TKA, FTB and ACB preserve quadriceps strength better than FNB at 6 h postoperatively, but there are no differences at 24 and 48 h. Moreover, this early inferiority does not translate to worse functional outcomes at any time point. FNB is associated with better pain control at 6, 24 and 48 h after surgery, while ACB presents the highest cumulative opioid requirement. CLINICAL TRIAL REGISTRATION: This study was registered in clinicaltrials.gov (NCT03518450; https://clinicaltrials.gov/ct2/show/NCT03518450 ; submitted March 17, 2018).

Sequential repeated tibial tubercle osteotomy in a two-stage exchange strategy: a superior approach to treating a chronically infected knee arthroplasty?

PURPOSE: Surgical approach can impact the reliability of the debridement after a chronic total knee periprosthetic joint infection (PJI), a factor of utmost importance to eradicate the infection. The most adequate knee surgical approach in cases of PJI is a matter of debate. The purpose of this study was to determine the influence of performing a tibial tubercle osteotomy (TTO) in a two-stage exchange protocol for knee PJI treatment. METHODS: Retrospective cohort study examining patients managed with two-stage arthroplasty due to chronic knee PJI (2010-2019). Performance and timing of the TTO were collected. Primary end-point was infection control with a minimum FU of 12 months and according to internationally accepted criteria. Correlation between TTO timing and reinfection rate was reviewed. RESULTS: Fifty-two cases were finally included. Overall success (average follow-up: 46.2 months) was 90.4%. Treatment success was significantly higher among cases addressed using TTO during the second stage (97.1% vs. 76.5%, p value 0.03). Only 4.8% of the patients relapsed after performing a sequential repeated TTO, that is, during both first and second stages, compared to 23.1% cases in which TTO was not done (p value 0.28). No complications were observed among patients in the TTO group with a significant decrease in soft tissue necrosis (p: 0.052). CONCLUSION: Sequential repeated tibial tubercle osteotomy during a two-stage strategy is a reasonable option and offers high rates of infection control in complex cases of knee PJI with a low rate of complications.

High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly.

PURPOSE: To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). METHODS: We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. RESULTS: Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. CONCLUSION: DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.

A comparative of a single novice surgeon's direct anterior approach and posterior approach learning curves in total hip arthroplasty: a retrospective cohort study.

INTRODUCTION: The purpose of the present study was to compare a novice surgeon's learning curves with the direct anterior approach and posterior approach in total hip arthroplasty. METHODS: A consecutive series of 376 total hip arthroplasties performed from November 2014 to September 2019 in a level-one healthcare center by a single surgeon (V.B) were retrospectively studied. Demographic data, functional outcomes, and complications were collected and compared. RESULTS: Within the ranks of the patients studied, we found differences between groups with respect to dislocation rate and length of stay; these were lower in the direct anterior approach (DAA) group. The approach was not associated with an increase in complications, but rather with a decrease in the rate of dislocations and better functional outcomes at 1-year follow-up. Operative time was initially higher with this approach, but equalized during the learning curve. CONCLUSION: The DAA can be safe even in the early stages of a novice surgeon's learning curve. It does not present a higher complication rate than the posterior approach, either in infection rate or in periprosthetic fractures. However, the DAA may provide greater functionality, lower dislocation rate and a shorter hospital stay. It can also be concluded that after having performed a certain number of interventions, operative time for the DAA can be comparable to that of other approaches.

Differential Replication for Credit Scoring in Regulated Environments.

Differential replication is a method to adapt existing machine learning solutions to the demands of highly regulated environments by reusing knowledge from one generation to the next. Copying is a technique that allows differential replication by projecting a given classifier onto a new hypothesis space, in circumstances where access to both the original solution and its training data is limited. The resulting model replicates the original decision behavior while displaying new features and characteristics. In this paper, we apply this approach to a use case in the context of credit scoring. We use a private residential mortgage default dataset. We show that differential replication through copying can be exploited to adapt a given solution to the changing demands of a constrained environment such as that of the financial market. In particular, we show how copying can be used to replicate the decision behavior not only of a model, but also of a full pipeline. As a result, we can ensure the decomposability of the attributes used to provide explanations for credit scoring models and reduce the time-to-market delivery of these solutions.

Environmental Adaptation and Differential Replication in Machine Learning.

When deployed in the wild, machine learning models are usually confronted with an environment that imposes severe constraints. As this environment evolves, so do these constraints. As a result, the feasible set of solutions for the considered need is prone to change in time. We refer to this problem as that of environmental adaptation. In this paper, we formalize environmental adaptation and discuss how it differs from other problems in the literature. We propose solutions based on differential replication, a technique where the knowledge acquired by the deployed models is reused in specific ways to train more suitable future generations. We discuss different mechanisms to implement differential replications in practice, depending on the considered level of knowledge. Finally, we present seven examples where the problem of environmental adaptation can be solved through differential replication in real-life applications.

Bilateral fracture of anterior tibial tuberosity with complete patellar tendon rupture in an adolescent patient.

Anterior tibial tuberosity fracture avulsion is an uncommon injury. A concomitant patellar rupture is even more scarcely encountered. We report the case of a 14-year-old male patient who suffered bilateral anterior tuberosity fractures with concomitant bilateral complete patellar tendon rupture. Adolescence, athletic activity, and high BMI may have contributed to this concomitant bilateral injury. Both lesions were treated in a one-stage repair surgery, performing an open reduction and internal fixation of the tibial tuberosity with a cannulated cortical screw and a primary tendon suture following the Krakow technique. To the authors' knowledge, no other cases of bilateral presentation of both lesions have been reported so far in the literature.

Massive Desmoplastic Fibroma of the Proximal Tibia: Case Report.

Desmoplastic fibroma of bone is a very uncommon, benign but locally aggressive fibrogenic tumor. This report describes the case of a 45-year-old patient with a massive desmoplastic fibroma of the proximal tibia. A two-staged surgical procedure was successfully performed: wide resection and endoprosthetic reconstruction. Surgeons should be aware of the complexity of its treatment in the locally advanced and aggressive cases. A comprehensive review of the literature is also provided.

Osteosarcoma After Total Knee Arthroplasty: A Case Report.

CASE: A 79-year-old woman presented with a periprosthetic fracture 8 years after a total knee arthroplasty (TKA). Radiographs demonstrated tibial implant loosening with severe osteolysis. A high-grade osteosarcoma around the prosthesis was diagnosed, and a supracondylar femoral amputation was performed. After 2 years, no complications have occurred. CONCLUSIONS: A malignant tumor around a TKA is extremely rare. Surgeons should remain vigilant with patients who present with rapidly progressive or very aggressive implant loosening with osteolysis. Owing to its complexity and potentially devastating prognosis, treatment should be guided by a specialist multidisciplinary team. Complex limb salvage procedures or amputation is usually required.

Characterization and treatment protocol of injuries inflicted to humans by synurbic European wild boars (Sus scrofa).

PURPOSE: Wild boar (Sus scrofa) has spread and colonized urban areas. The closer contact with humans can lead to wild boar-inflicted injuries. The objectives of this study are: 1) to systematically review the literature on wild boar-inflicted injuries; 2) to describe our wild boar-inflicted wound management protocol; and 3) to analyse the features, outcomes and complications of our case series. METHODS: First, a systematic search of the literature was performed using the PubMed (MEDLINE) electronic database. Then, our evidence-based wild boar-inflicted wound management protocol was described. Finally, a retrospective case series study including all the patients with wild boar-inflicted injuries attended in our Emergency Department (2020-2022) was analysed. RESULTS: Fourteen studies (twelve case reports and two case series) were selected for the literature review. Our case series included 34 patients: 50.0% of them presented superficial wounds and 38.2% penetrating wounds. Most of the wounds occurred in the lower limbs (71.9%). Following our protocol, 30.0% of the wounds were primarily closed, the 70.0% of the patients received antibiotics (92.3% in penetrating injuries) and the 26.7% received an antitetanic vaccine. Only one patient (2.9%) presented a complication. CONCLUSIONS: This study reports the first specific wild boar inflicted-wound management protocol, which led to a low complication rate. Open wounds affecting the lower limbs were the most common lesions. Care should be taken with penetrating tusk injuries. Wide-spectrum antibiotic and antitetanic treatments are recommended. Decisions on wound management should be taken case-by-case, while antirabies vaccination depends on the local status of the disease.

First surgical experience treating scoliosis using HGT and ECMO: a case report.

CASE PRESENTATION: A 13-year-old female with congenital diaphragmatic hernia-associated pulmonary hypertension presented with severe and rapidly progressing scoliosis. The patient suffered from chronic respiratory failure and high risk of hypertensive crisis with potentially life-threating consequences. The scoliosis was treated with a multidisciplinary approach combining preoperative halo-gravity traction, venoarterial extracorporeal membrane oxygenation support and posterior spinal instrumented fusion. After 2 years of follow-up, results are excellent. CONCLUSIONS: The treatment combination reported here for the first time aims to limit surgical aggressiveness. It could be an effective and safe approach for treating severe spinal deformities in very fragile patients with high surgical risk.

Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport.

Aim: Distal tibial injuries combining bone loss, articular destruction and infection can be treated through distraction osteogenesis combined with ankle fusion. Bone transport is not without complications. This study investigates our preliminary results using a retrograde prefabricated gentamicin-coated nail (ETN PROtect®) to treat complications after infected bone defects of the distal tibial were managed by ankle arthrodesis and distraction osteogenesis. Materials and methods: This is a retrospective case series study. All consecutive patients with bone transport complications after ankle arthrodesis and distraction osteogenesis who were subsequently operated on using a retrograde ETN PROtect® nail were analysed. The cases occurred between 2017 and 2020. The primary objective was to report on the resolution of the clinical problem and the risk of deep infection after nail implantation. Results: Five patients have included: two docking site non-unions, two regenerated bone fractures and one hypotrophic regenerated bone. These complications were resolved in all patients (5/5, 100%). A painless, stable and plantigrade ankle arthrodesis was achieved in all cases. No patient developed a local infection or required nail removal (mean follow-up: 35.2 months). The mean LEFS score was 46.8 ± 13.8 and the mean knee ROM was 112 ± 12.7°. All patients tolerated full weight-bearing. All patients were very satisfied with the procedure (mean SAPS score was 93.8 points). Conclusion: The staged retrograde nailing technique using the ETN PROtect® nail may represent an effective and safe treatment for bone transport complications in high-infection-risk patients. Furthermore, the technique allows simultaneous achievement of ankle arthrodesis. The patients had good functional outcomes and were satisfied with the procedure. Clinical significance: This strategy of using retrograde gentamicin-coated tibial nails offers a solution to resolve bone transport complications while simultaneously achieving functional ankle arthrodesis. How to cite this article: Pujol O, Vicente M, Castellanos S, et al. Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport. Strategies Trauma Limb Reconstr 2023;18(3):155-162.

Atraumatic Fracture of the Femoral Component of a Cemented Total Knee Arthroplasty: A Case Report.

CASE: An 81-year-old man presented with severe atraumatic knee pain. Sixteen years before, he had undergone a primary cemented total knee arthroplasty (TKA). A radiological study showed osteolysis and loosening of the femoral component. Intraoperatively, a medial femoral condyle fracture was found. A rotating-hinge revision TKA with cemented stems was implanted. CONCLUSION: Femoral component fracture is extremely rare. Surgeons should remain vigilant with younger and heavier patients with severe unexplained pain. Early revision TKA using cemented, stemmed, and more constrained implants is usually necessary. Full and stable metal-to-bone contact through perfect cuts and a careful cementing technique avoiding debonded areas are recommended to prevent this complication.

Should we employ preoperative templating in hip hemiarthroplasty after femoral neck fracture? A nested case-control study.

INTRODUCTION: Dislocation following hip hemiarthroplasty is a serious complication. It remains unclear if acetabular morphology is associated with a higher risk of dislocation. The aim of our study was to investigate whether there are differences in hip morphology radiological parameters between patients who have suffered a dislocation episode, and those who have not suffered a dislocation. MATERIAL AND METHODS: Between January 2015 and December 2018, a nested case-control study was performed. From 707 patients who underwent hip hemiarthroplasty because of femoral neck fracture, 50 patients (50 hips) suffered an episode of dislocation. They were randomly matched with 94 patients (100 hips) without dislocation (ratio 1:2). Clinical data regarding demographics, medical comorbidities and surgical and radiological parameters were studied. RESULTS: Statistically significantly smaller lateral centre-edge angle (LCEA) and femoral offset (FO) and greater Tönnis angle were found in the dislocation group. No differences in acetabular angle were seen. Neurological impairment prevalence was statistically significantly higher in patients who suffered a dislocation (60% vs. 44%, p = 0.011). CONCLUSIONS: The current study suggests that a smaller LCEA and FO, a greater TA, and neurological impairment could be related to a higher risk of hip hemiarthroplasty dislocation after femoral neck fracture in the elderly. We consider that preoperative templating could be helpful in identifying abnormal parameters and carefully planning surgery could lead to changes in treatment strategy, such as choosing a dual-mobility total hip arthroplasty.

Considerations of the Posterior Tibial Slope in Anterior Cruciate Ligament Reconstruction: a Scoping Review.

PURPOSE OF REVIEW: The significance of posterior tibial slope (PTS) in the setting of anterior cruciate ligament (ACL) injury and reconstruction has been increasingly recognized in recent years. The purpose of this article is to review the biomechanical and clinical studies of PTS in conjunction with ACL injuries, providing an evidence-based approach for the evaluation and management of this patient population. RECENT FINDINGS: Several biomechanical and clinical studies suggest that PTS > 12° may be considered with increased strain on the native ACL fibers (or reconstructed graft) and greater anterior tibial translation, predisposing patients to a recurrent ACL injury. The increased rates of ACL injury and graft failure seen in those with increased PTS have garnered attention to diagnose and surgically address increased PTS in the revision ACL setting; however, the role of a slope-reducing high tibial osteotomy (HTO) in primary ACL reconstruction (ACL-R) has yet to be defined. Various HTO techniques to decrease PTS during revision ACL-R have demonstrated promising outcomes, though conclusions are limited by the multifactorial nature of revision surgery and concomitant procedures performed. Recent evidence suggests that increased PTS is a risk factor for failure following ACL-R, which may be mitigated by a slope-reducing HTO. Further investigation is needed to elucidate abnormal PTS values and to determine appropriate indications for a slope-reducing HTO in primary ACL-R.